Julie Stefanski MEd, RDN, CSSD, LDN, CDE
While the word “hangry” was only added to the Oxford English Dictionary in 2018, the connection between our food choices and our mood is clear to anyone who’s ever gotten testy when mealtime was delayed or turned to a comfort food for emotional support.
October 11, 2018 is National Depression Screening Day https://mentalhealthscreening.org/media/fact-sheet-national-depression-screening-day.
Registered Dietitian Nutritionists are in a unique position to screen for mental health issues including depression that may not have been addressed appropriately. While clients may seek help regarding excessive weight gain or weight loss from a dietitian, those two nutrition issues are just one example of a possible side effect from an underlying psychological issue such as anxiety or depression.
Jennifer Pelton, LCSW, a licensed social worker in York, PA points out that depression can take many forms depending on the persons’ identified type of disorder according to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders. Pelton explained, “There are a few types of patterns an RD may identify in a client. One type could be someone who can’t perform daily activities due to extreme lack of energy and engagement in everyday jobs/roles. Another person may be over eating or using binge type behaviors in order to compensate for negative emotions, and is using eating as a form of coping.”
Screen for Depression
During the task of gathering medical and social history on a client, a dietitian may casually pick up on signs of depression, but there are also some tools to assist healthcare providers in screening for depression including PHQ-9 or Mood and feelings Questionnaire (MFQ) – short version.
Dietitians should be on the lookout for other food related behaviors that may indicate depression such as:1
• Lack of interest in eating
• Change in appetite
• Weight gain or weight loss
• Feel unworthy of eating, lack of motivation, or poor energy levels
• No desire to shop or prepare food
• Poor food hygiene presenting food safety risks
• Thoughts of not being able to eat or being physically too ill to eat
• Preferences for liquid and/or convenience foods; require less energy to prepare and eat
Pelton added, “Being aware of the patient’s eating habits, understanding depressive symptoms, and how the individual’s symptoms impact their daily living activities may help an RD to make a recommendation for counseling. Managing depressive symptoms before addressing nutritional deficits or working to provide a collaborative approach with a behavioral health specialist is best in order to work on mental health and nutrition cohesively.
Screen for Food Insecurity
There is a growing awareness of the impact that food insecurity can have on both chronic illness and emotional health. While lack of nourishing food can create micronutrient imbalances which contribute to mental health issues, food insecurity itself can create feelings of anxiety and depression. Screening for depression is important among nutrition professionals, but screening for nutrition issues and food insecurity is vitally important for those who work with clients in behavioral health.
Everyone can screen for food insecurity by asking a few simple questions. The American Academy of Pediatrics offers a valuable resource called Addressing Food Insecurity: A Toolkit for Pediatricians that can be used by any healthcare provider.
The AAP toolkit suggests this phrasing when delving into hunger issues, “I’m seeing so many people that are having a hard time affording food, so I’m asking all of my patients some questions about this. Please let me know if either of these statements is true for you and your family…”
Two questions make up what’s known as The Hunger Vital Sign,™ a validated two-question food insecurity screening tool derived from USDA’s 18-question Household Food Security Scale.
1. Within the past 12 months, we worried whether our food would run out before we got money to buy
• often true
• sometimes true
• never true
• don’t know/refused
2. Within the past 12 months, the food we bought just didn’t last and we didn’t have money to get more.
• often true
• sometimes true
• never true
• don’t know/refused
An individual is at risk of food insecurity if “often true” or “sometimes true” to either statement is true and should be offered with their permission information about local food access services.
Resources in your community for addressing food insecurity can be found at: http://www.feedingamerica.org/need-help-find-food/
Beth Conway, MS, RDN, LDN, a dietitian who specializes in eating disorders must often walk the fine line between identifying an emotional eating issue and actually addressing the emotions behind it.
Conway explained, “You need a team approach if there are mental health issues. Therapists are often underutilized in eating issues and there’s so many emotions behind eating behaviors such as binge eating or bulimia. It’s important to make the referral to a behavioral therapist to develop joint behavioral and eating goals.”
When faced with stepping into an area that may beyond a registered dietitian’s scope of practice Conway suggests clarifying this clearly with the client. She shared, “I may say to my client, ‘I think we’ve identified a great point, but that is probably suited better for a discussion with your therapist,’ or ‘perhaps you can come up with some more coping strategies for this issue with your therapist.’” This helps the client to identify which issues are addressed by the dietitian versus the therapist as they work together on the interdisciplinary treatment team.
The Future of Mental Health and Nutrition
Good nutrition is important in supporting ideal mental and physical health as someone seeks treatment for their depression. Some experts believe that negative changes in our typical diets, with a shift from a varied diet based on whole foods to frequent consumption of ultra-processed foods is not helping to support good mental health in the U.S. While many areas of nutrition have been investigated for their impact on mental health, one area in particular where there is a growing interest is in the role of gut health on behavior.
Nutrients and probiotics (often referred to as ‘beneficial bacteria’) have been shown in both animal and human studies to benefit mood and influence what’s known as the Gut Brain Axis. Perhaps research in the future will reveal what particular strain of bacteria can be beneficial for promoting a boost in mood, anxiety or depression. You can learn much more about this area of study and the connection between our microbiome and our mental health in our webinar Guts to Be Healthy.
1. Davison KM, Ng E, Chandrasekera U, Seely C, Cairns J, Mailhot-Hall L, Sengmueller E, Jaques M, Palmer J, Grant-Moore J for Dietitians of Canada. Promoting Mental Health through Healthy Eating and Nutritional Care. Toronto: Dietitians of Canada, 2012.